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Enhanced Recovery Pathway

Enhanced Recovery logo

The evidence-based colon and rectal surgery enhanced recovery pathway (ERP) went live on February 14, 2012. Hospital length of stay and patient outcomes were noticeably improved soon after the implementation of this multi-disciplinary protocol. Many patients have recovered and been discharged on postoperative day 2, and many robotic patients on postoperative day 1 or same day. A collaborative effort to include specialists in Nutrition, Case Management, Social Work, Home Care, Patient Care Unit Nursing, Anesthesia, Pharmacy, and other related disciplines emphasizes preadmission education, carbohydrate loading, state-of-the-art multimodal pain management, early feeding, early mobilization, and comprehensive discharge planning as components of the protocol responsible for success of this program.

Dr. Cleary was awarded a $102,000 grant from the Blue Cross Blue Shield Foundation of Michigan (BCBSM) to fund this Enhanced Recovery Pathway. This research project was published in 2016 and demonstrated that the program decrease hospital LOS by 2 days.

Subsequent studies by our group showed that readmissions are significantly decreased with ERP upgrades that include a mobile phone app that delivers preadmission push notification patient reminders and postoperative questions about common complications that patients respond to and that are monitored 24/7. The ERP also includes a pharmacist-led multimodal pain management strategy with emphasis on non-opioids, and unlimited high-level standardized and regimented post-discharge clinic visits for ileostomy patients.

  1. Martin TD, Lorenz T, Ferraro J, Chagin K, Lampman RM, Emery KL, Zurkan JE, Boyd JL, Montgomery K, Lang RE, Vandewarker JF, Cleary RK. Newly Implemented Enhanced Recovery Pathway Positively Impacts Hospital Length of Stay. Surg Endosc 2016; 30(9):4019-4028
  2. Mouawad NJ, Leichtle SW, Kaoutzanis C, Welch K, Winter S, Lampman R, McCord M, Hoskins KA, Cleary RK. Pain control with continuous infusion preperitoneal wound catheters versus continuous epidural analgesia in colon and rectal surgery: a randomized controlled trial. Am J Surg. 2018;215:570-576
  3. Felling DR, Jackson M, Ferraro J, Battaglia MA, Albright J, Wu J, Genord CK, Brockhaus KK, Bhave RA, McClure AM, Shanker BA, Cleary RK. Liposomal Bupivacaine Transversus Abdominis Plane Block versus Epidural Analgesia in a Colon and Rectal Surgery Enhanced Recovery Pathway: A Randomized Clinical Trial. Dis Colon Rectum 2018;61:1196-1204
  4. Stapler SJ, Brockhaus KK, Battaglia MA, Mahoney ST, McClure AM, Cleary RK. A single institution analysis of targeted colorectal surgery enhanced recovery pathway strategies that decrease readmissions. Dis Colon Rectum 2023;89:6091-6097 PMID 37482697
  5. Westfall KM, Rivard SJ, Suwanabol PA, Albright J, Ramm C, Cleary RK. Postoperative oral rehydration and regimented follow-up decrease readmissions for colorectal surgery patients with ileostomies. Dis Colon Rectum 2024;67:313-321 PMID 37703205
  6. Kamara M, Baur K, Langmeyer J, Huebner M, Ramm C, Cleary RK. Early discharge after enhanced recovery rectal resection does not increase emergency department visits and readmissions: A single institution analysis. Surg Endosc 2024;38:4251-4259 PMID 38862825
  7. Baur K, Sood EM, Huebner M, Ramm C, Kolli N, Cleary RK. Early discharge after enhanced recovery colectomy does not increase emergency department visits and readmission: A single institution analysis. Am Surg 2024;90:1439-1446 PMID: 38520237